The Potential Benefits of Applying Recent Advances in Esophageal Motility Testing in Patients with Esophageal Atresia

Esophago-gastric junction findings on high resolution impedance manometry in children with esophageal atresia

OBJECTIVES

Using high resolution impedance manometry (HRIM), this study characterized the esophago-gastric junction (EGJ) dynamics in children with esophageal atresia (EA).

METHOD

Esophageal HRIM was performed in patients with EA aged less than 18 years. Objective motility patterns were analyzed, and EGJ data reported. Controls were pediatric patients without EA undergoing investigations for consideration of fundoplication surgery.

RESULTS

Seventy-five patients (M:F = 43:32, median age 1 year 3 months [3 months-17 years 4 months]) completed 133 HRIM studies. The majority (64/75, 85.3%) had EA with distal tracheo-esophageal fistula. Compared with controls, liquid swallows were poorer in patients with EA, as evident by significant differences in distension pressure emptying and bolus flow time (BFT). The integrated relaxation pressure for thin liquid swallows was significantly different between EA types, as well as when comparing patients with EA with and without previous esophageal dilatations. The BFT for solid swallows was significantly different when compared with EA types.

CONCLUSIONS

We have utilized HRIM in patients with EA to demonstrate abnormalities in their long-term EGJ function. These abnormalities correlate with poorer esophageal compliance and reduced esophageal peristalsis across the EGJ. Understanding the EGJ function in patients with EA will allow us to tailor long-term management to specific patients.

Feeding and Swallowing Characteristics of Children With Esophageal Atresia and Tracheoesophageal Fistula

OBJECTIVES

This study aimed to characterize feeding/swallowing difficulties in children with esophageal atresia and/or tracheoesophageal fistula (EA/TEF) and evaluate associations among feeding difficulties, pharyngeal dysphagia (PD), and other aerodigestive evaluation findings.

METHODS

This was a retrospective cohort study of feeding/swallowing characteristics of 44 patients with EA/TEF treated in the aerodigestive program of a single academic medical institution from 2010 to 2015. Demographics, comorbidities, presence and characteristics of feeding/swallowing difficulties, and results of relevant diagnostic tests [videofluoroscopic swallow studies (VFSS), clinical feeding evaluations (CFEs), chest computerized tomography (CT) scans, pulmonary bronchoscopies, and upper GI (UGI)/esophagrams] were reviewed.

RESULTS

Fifty percent of the cohort had PD and 88.6% had feeding difficulties. Across 118 encounters (87 VFSS and 31 CFEs), feeding difficulties suggestive of esophageal dysphagia were most frequently seen in children over 48 months and feeding difficulties suggestive of developmental feeding problems were most frequently seen in children from 24 to 48 months. Abnormal findings were present in 59.8% of VFSS, with aspiration (34.5%) and pharyngeal residue (26.4%) the most frequently observed signs of dysphagia. Abnormal UGI/esophagram findings were not associated with significantly increased risk of feeding difficulties during visits within 3 months (risk ratio, RR = 1.33). Presence of dysphagia was associated with increased risk for some abnormal CT findings (RR= 3.0 for airspace and 3.0 for bronchiectasis).

CONCLUSIONS

Feeding/swallowing difficulties are common in EA/TEF, and types of feeding difficulties vary by patient age. The presence of abnormal findings on UGI/esophagram did not increase the risk of feeding complaints; however, the presence of dysphagia increased the risk of abnormal chest CT.

Fiberoptic endoscopic evaluation of swallowing (FEES) study: the first report in children to evaluate the oropharyngeal dysphagia after esophageal atresia repair

BACKGROUND

The aim of this study was to evaluate the swallowing problems by fiberoptic endoscopic evaluation of swallowing (FEES) study in both short- and long-gap patients after esophageal atresia (EA) repair.

METHODS

Hospital records of patients who had undergone surgery for EA were reviewed retrospectively. Patients were divided into two groups as short-gap (SG) group (n:16) and long-gap (LG) group (n:10) to compare the swallowing problems. FEES study was performed, and the results were discussed in detail.

RESULTS

There were twenty-six (16 M/10 F) patients with a mean age at evaluation was 7.52 ∓ 3.68 years. Mean follow-up period was 75.35 ∓ 44.48 months. In FEES study, pharyngeal phase abnormalities were detected in 10 patients (38.4%). Pharyngeal phase abnormalities were detected significantly higher in LG group (p:0.015). Laryngeal penetration/aspiration was seen in four patients on FEES study (15.3%). All of them was in LG group (40%). Laryngeal penetration/aspiration was seen significantly higher in LG group (p:0.014).

CONCLUSION

This is the first study to conduct FEES study in children after esophageal atresia repair to evaluate their swallowing conditions. Even though our sample is small, swallowing problems are more common than expected in the cases of LG when compared to SG.

Role of Esophageal High-Resolution Manometry in Pediatric Patients

PURPOSE

Dysphagia, vomiting and feeding difficulties are common symptoms, with which children present. Esophageal function testing with high resolution manometry can help in diagnosing and treating these patients. We aim to access the clinical utility of high-resolution manometry of esophagus in symptomatic pediatric patients.

METHODS

A retrospective chart review was done on all symptomatic patients who underwent esophageal high-resolution manometry between 2010 and 2019 at Sydney Children's Hospital, Australia. Manometry results were categorized based on Chicago classification. Demographic data, indication of procedure, manometric findings, and details of treatment changes were obtained and analyzed.

RESULTS

There were 62 patients with median age of 10 years (9 months-18 years). The main indication for the procedure was dysphagia (56%). Thirty-two percent of patients had a co-morbid condition, with esophageal atresia accounting for 16%. The majority (77%) of patients had abnormal manometry which included, ineffective esophageal motility in 45.2%. In esophageal atresia cohort, esophageal pressurization was seen in 50%, aperistalsis in 40% and 10% with prior fundoplication had esophago-gastric junction obstruction. Patients with esophago-gastric junction obstruction or achalasia were treated by either pneumatic dilation or Heller's myotomy. Patients with ineffective esophageal motility and rumination were treated with a trial of prokinetics/dietary texture modification and diaphragmatic breathing.

CONCLUSION

Esophageal high-resolution manometry has a role in the evaluation of symptomatic pediatric patients. The majority of our patients had abnormal results which led to change in treatments, with either medication, surgery and/or feeding modification with resultant improvement in symptoms.

Clinical Experience With Performing Esophageal Function Testing in Children

OBJECTIVES

Pediatric high-resolution manometry (HRM) and 24-hour pH-impedance with/without ambulatory manometry (pH-MII+/-mano) tests are generally performed using adult-derived protocols. We aimed to assess the feasibility of these protocols in children, the occurrence of patient-related imperfections and their influence on test interpretability.

METHODS

Esophageal function tests performed between 2015 and 2018 were retrospectively analyzed. All tests were subcategorized into uninterpretable or interpretable tests (regardless of occurrence of patient-related imperfections). For HRM, the following patient-related imperfections were scored: patient-related artefacts, multiple swallowing and/or inability to establish baseline characteristics. For pH-MII(+/-mano), incorrect symptom registration and/or premature catheter removal were scored. Results were compared between age-groups (0-3, 4-12, and >12 years).

RESULTS

In total 106 HRM, 60 pH-MII, and 23 pH-MII-mano could be fully analyzed. Of these, 94.8% HRM, 91.9% pH-MII, and 95.7% pH-MII-mano were interpretable. Overall, HRM contained imperfections in 78.3% overall and in 8/8 (100%) in the youngest age group, 36/42 (85.7%) in 4 to 12 years and in 37/56 (66.1%) in children above 12 years; P = 0.011. These imperfections led to uninterpretable results in 4 HRM (3.8%), of which 3 were in the youngest age group (3/8, 37.5%). Imperfections were found in 10% of pH-MII and 17.4% of pH-MII-mano. These led to uninterpretable results in 5.0% and 4.3%, respectively. No age-effect was found.

CONCLUSIONS

Esophageal function tests in children are interpretable in more than 90% overall. In children under the age of 4 years, all patients had imperfect HRM and 3/8 tests were uninterpretable. HRM in older children and pH-MII+/-mano were interpretable in the vast majority.

What is the role of high-resolution oesophageal manometry in paediatrics?

Abnormal oesophageal motility may impair oesophageal bolus transport leading to symptoms of chest pain and regurgitation. Oesophageal pathophysiology may include neuromuscular and/or structural defects leading to weak, incoordinate or absent peristalsis and impaired oesophago-gastric junction relaxation. Understanding these mechanisms is important to determine the appropriate course of therapy. Whilst, barium oesophagram is the mainstay for clinical investigation of oesophageal motility, high-resolution manometry is now more widely available. This review describes the potential value of high-resolution manometry in paediatric gastroenterology practise.

Pressure-impedance analysis: Assist the diagnosis and classification of ineffective esophageal motility disorder

BACKGROUND AND AIM

We elucidated the clinical significance of distal contractile integral-to-esophageal impedance integral (EII) ratio (DCIIR) in ineffective esophageal motility (IEM) adult patients.

METHODS

We recruited 101 patients with IEM (48.38 ± 1.58 years) and 42 matched healthy volunteers (44.28 ± 1.85 years) in this case-control study. All subjects underwent esophageal high-resolution impedance manometry from October 2014 to May 2018. The diagnosis of IEM was based on the Chicago Classification version 3.0. The EII, EII ratio, and DCIIR were analyzed by matlab software.

RESULTS

The EII, EII ratio, and DCIIR calculated at an impedance threshold of 1500 Ω (EII1500, EII ratio1500, and DCIIR1500, respectively) were significantly lower in the IEM group than in healthy controls (P < 0.0001, < 0.0001, and < 0.0001, respectively). Receiver operating characteristic analysis showed that DCIIR1500 < 0.008 mmHg/Ω, EII1500 > 71 000 Ω.s.cm, and EII ratio1500 > 0.43 were all predictive of IEM. Only DCIIR1500 < 0.008 mmHg/Ω remained significant in diagnosing IEM in the multivariate logistic regression analysis (odds ratio = 72.13, P < 0.001). The DCIIR1500 is negatively correlated with Eckardt score and the Reflux Disease Questionnaire (correlation coefficient = -0.2844 and -0.3136; P = 0.0006 and 0.0002, respectively). Receiver operating characteristic analysis further showed that a DCIIR1500 cut-off of 0.002 mmHg/Ω achieved the best differentiation between the IEM-alternans and IEM-persistens subtypes among IEM patients (P < 0.001).

CONCLUSIONS

The novel pressure-impedance parameter of high-resolution impedance manometry, DCIIR1500, may assist in the diagnosis and classification of IEM and correlated with clinical symptoms.

Neonatal factors predictive for respiratory and gastro-intestinal morbidity after esophageal atresia repair

BACKGROUND

Esophageal atresia is a major congenital foregut anomaly. Affected patients often suffer from respiratory and gastro-intestinal morbidity. The objective of this study is to identify possible neonatal predictive factors contributing to a long-term complicated clinical course in patients after repair of esophageal atresia.

METHODS

A total of 93 patients born between 1993 and 2013, with esophageal atresia and surviving the neonatal period were included in this retrospective study. A complicated clinical course was defined as the occurrence of ≥1 of these complications: severe gastro-esophageal reflux, esophageal stricture requiring dilatations, need for tube feeding for >100 days, severe tracheomalacia, severe chronic respiratory disease and death. We used linear models with a binomial distribution to determine risk factors for gastro-intestinal or respiratory complicated evolution and a backward stepwise elimination procedure to reduce models until only significant variables remained in the model. Multinomial logistic regression was used to assess risk factors for different evolutions of complication. Model parameter estimates were used to calculate odds ratios for significant risk factors.

RESULTS

Fifty-seven patients (61%) had a complicated clinical course in the first year of life and 47 (51%) had a complicated evolution during years 1-6. In the first year, prematurity was a significant factor for complicated gastro-intestinal (OR 2.84) and respiratory evolution (OR 2.93). After 1 year, gastro-intestinal morbidity in childhood was associated with VACTERL association (OR 12.2) and a complicated first year (OR 36.1). Respiratory morbidity was associated with congenital heart disease (OR 12.9) and a complicated first year (OR 86.9). Multinomial logistic regression showed that prematurity (p = 0.018) and VACTERL association (p = 0.003) were significant factors of complications.

CONCLUSION

Prematurity is an important predictive factor for a complicated clinical course in early life. A complicated first year often predicts a complicated clinical course in childhood. These risk factors may be helpful in counseling of parents in the neonatal period.

Oesophageal atresia

Oesophageal atresia (EA) is a congenital abnormality of the oesophagus that is caused by incomplete embryonic compartmentalization of the foregut. EA commonly occurs with a tracheo-oesophageal fistula (TEF). Associated birth defects or anomalies, such as VACTERL association, trisomy 18 or 21 and CHARGE syndrome, occur in the majority of patients born with EA. Although several studies have revealed signalling pathways and genes potentially involved in the development of EA, our understanding of the pathophysiology of EA lags behind the improvements in surgical and clinical care of patients born with this anomaly. EA is treated surgically to restore the oesophageal interruption and, if present, ligate and divide the TEF. Survival is now ~90% in those born with EA with severe associated anomalies and even higher in those born with EA alone. Despite these achievements, long-term gastrointestinal and respiratory complications and comorbidities in patients born with EA are common and lead to decreased quality of life. Oesophageal motility disorders are probably ubiquitous in patients after undergoing EA repair and often underlie these complications and comorbidities. The implementation of several new diagnostic and screening tools in clinical care, including high-resolution impedance manometry, pH-multichannel intraluminal impedance testing and disease-specific quality of life questionnaires now provide better insight into these problems and may contribute to better long-term outcomes in the future.

Piecemeal Deglutition and the Implications for Pressure Impedance Dysphagia Assessment in Pediatrics

OBJECTIVES

High-resolution impedance manometry (HRIM) enables biomechanical swallow assessment. Piecemeal deglutition (PD) defines swallowing of a single bolus in 2 or more portions. We investigated PD sequences on HRIM recordings to ascertain appropriate swallow selection for analysis and to determine the impact of PD on swallow function measures.

METHODS

Pharyngo-esophageal motility and bolus flow were assessed in 27 children (19 M, mean age 15 months) with repaired esophageal atresia and trachea-esophageal fistula, but who were asymptomatic of oropharyngeal dysphagia. A consistent volume of between 2 and 5 mL saline boluses was given to each patient. Retrospectively, PD sequences were defined based on the number of swallows required to clear the bolus from the oral cavity: pattern A = 1-2 swallows; pattern B = 3 swallows; and pattern C = 4+ swallows. The largest bolus volume swallowed was noted as the dominant swallow in each pattern. Pressure Flow Analysis defined contractility, distension and flow timing metrics. Data were averaged for each PD pattern, and compared with dominant swallows from each pattern.

RESULTS

PD pattern B (43.7%) was the most prevalent across the cohort. PD patterns were similarly distributed across age groups (G1: <1 years, G2: 1-4 years). Differences in upper esophageal sphincter distension and pharyngeal flow timing measures were, however, seen in relation to both age and PD pattern, whereby a larger pharynx in older children elicited greater distension for a longer latency, and for larger volumes.

CONCLUSIONS

PD reduces bolus volume, and biomechanical swallow measures are impacted. PD is a necessary consideration for accurate HRIM analysis of swallow function. Selection of dominant swallows from a PD sequence provides a swallow profile which best represents a child's swallow function, and should always be reported and interpreted in context of the PD sequence observed.

Distal contractile to impedance integral ratio assist the diagnosis of pediatric ineffective esophageal motility disorder

OBJECTIVES

We investigated the diagnostic utility of distal contractile integral (DCI) to esophageal impedance integral (EII) ratio (DCIIR) in high-resolution impedance manometry (HRIM) of ineffective esophageal motility (IEM) in children.

METHODS

We performed HRIM in 31 children with dysphagia, odynophagia, chronic vomiting, chest pain, or heartburn sensation. Based on the Chicago classification version 3.0, 20 subjects were diagnosed with IEM, and 11 subjects were normal. We analyzed the EII and DCIIR using MATLAB software.

RESULTS

The DCIIR calculated at the impedance cutoff at 1500 Ω (DCIIR1500) were significantly lower in IEM group than patients with normal motility (P = 0.007). Receiver operating characteristic (ROC) curve analysis showed that a DCIIR1500 < 0.009 mmHg/Ω best predicted IEM in children (P < 0.001). A DCIIR1500 < 0.008 mmHg/Ω is associated with significant body weight loss > 10% within 6 months in children. (P < 0.001).

CONCLUSIONS

The calculation of DCIIR1500 may assist the automatic analysis of bolus transit in HRIM study to diagnose IEM in children. An DCIIR1500 < 0.009 mmHg/Ω may assist in the diagnosis of IEM in children, and DCIIR1500 < 0.008 mmHg/Ω correlated with significant body weight loss. The calculation of DCIIR may serve as possible parameters for HRIM.